Evangelos Oikonomou1 MD*, Angelos Papanikolaou1 MD*, Aris Anastasakis2 MD, Elefterios Bournousouzis3 MSc, Christos Georgakopoulos1, John Goudevenos4 MD, Nikolaos Ioakeimidis1 MD, John Kanakakis5 MD, George Lazaros1 MD, Stathis Papatheodorou2 MD, Adalena Tsatsopoulou6 MD, Paraskevi Tsonou3 MD, Georgia Vogiatzi1 MD, George Panagiotakopoulos3 MD, Dimitris Tousoulis1 MD, Charalambos Vlachopoulos1 MD2
Coronavirus disease 2019 (COVID-19) is an acute respiratory disease of various severity caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) [1, 2]. Cardiovascular system is the second most significant target of COVID-19  and involvement includes acute myocardial injury, myocarditis, arrhythmias and venous thromboembolism. Reports document that in patients with COVID-19 the incidence of myocardial injury is estimated at 28% and is associated with fatal outcome . In the acute phase of myocarditis exercise may exacerbate viral replication, inflammation, myocardial cell death, arrhythmias and may adversely affect the outcome leading to morbid complications.
Taken into consideration the uncertainties regarding prevalence of asymptomatic COVID-19 cases in the community, the incidence of myocardial injury in COVID-19 patients with mild symptoms and the long term outcome of COVID-19, public health policy is required to guide the return-to-sports decision making especially for competitive athletes achieving the higher workload and intense exercise training. The present document provides an algorithm for the evaluation and management of athletes (over 14 years old) following infection from SARS-CoV-2 (Figure 1) based of expert opinion and taking into account the position statements of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases on management of myocarditis  and of Sport Cardiology Section of the European Association of Preventive Cardiology on management of athletes with myocarditis .